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A few days ago I ran into a friend who I have had two conversations with prior to seeing her again on the street. She told me, “I’ve been thinking a lot about you over the last few days. All of the feelings of sadness that I have, I just envision that you are experiencing them 10 fold.”

I ride two bicycles, one for commuting and one for happiness (going fast). Sometimes when I’m on my bike I get sad. I know, I said I have a bike for happiness, and trust me it makes me unbelievably happy.

But when I’m out riding the trails and going fast, I rarely see women on bikes. On a typical day I’ll pass dozens of men with fancy bikes and riding gear “going fast” (let’s face it, I leave all of them in my dust). But I rarely see women out riding. In fact, I often get looks of confusion or maybe pride from men out riding. One time, when I passed a group of male riders, one said “oh hell no, we can’t let a girl beat us.” It’s so rare to see women on the trail that it seems foreign, even in Massachusetts.

Cycling requires some high up front costs and yes, it can be dangerous. I’ve gotten hit 3 times and have the scars and bruises to prove it. But I also have tripped running a dozen times and have the scars to prove that as well. My knees are basically scar tissue.

When I go to spin classes they are usually 60-80% female. So I know women know and enjoy riding.

There is something magical about the wind in your hair and the sun shining down on your face. Boston has some beautiful trails and it takes about 5 minutes to get from the bustling city to nature.

I’m really only writing this to remind myself how much I love cycling and how much of a badass it makes me feel like for the next time I’m lying on my bed too lazy to hit the trails.

Every year I take the Federal Presidents’ Day holiday seriously and observe a President by learning about them and their lives. This year was a biggie- #16.

Here are the things I learned about our greatest President:

1. Mary Todd Lincoln, has often been called bipolar. I’m partial to think that the crazy label was a lot of pre-feminism, pre-suffrage understanding of her. She had a rough life (as if life in the mid-19th century wasn’t rough enough already) and was scrutinized in the public eye more than any other woman of her time. She was very well educated, getting a graduate degree and had dimples (like me!). When Lincoln met her he said “I want to dance with you in the worst way.” and she told her cousin “he certainly did.”

-Bonus fact! Mary was originally courted by Stephan A. Douglas but she went for Lincoln instead. Yeah, that’s right. The Douglas of Lincoln-Douglas debates. No wonder it was so fiery!

2. On to another romantic angle to Lincoln, he was ghosted! For those of you not familiar with the term, read this. Lincoln was originally courting a woman named Mary Owens for about a year, even getting her to move for him. He proposed to her in probably the least romantic way possible. This seemed to cause problems in their relationship and he sent her a letter saying that it would be fine if she ended things. And she never wrote back!! Melodramatic Lincoln said he’d never find love again after that failed attempt. Very soon after, he danced with Mary Todd. Marys, amiright?

3. It’s been noted that Lincoln initially never wanted to embrace the slavery issue, but he had a record of fighting for justice. Long time readers will remember 2011 when we learned about James Knox Polk. During this time Lincoln was serving in the House and was opposed to the Mexican American war. He drafted the Spots Resolutions that demanded to know the exact spots where blood fell in the war. Polk had said that we were attacked on American soil; good old Abraham didn’t believe him. Of course, no one really cared about Lincoln and his first and only term he promised to his district ended.

The CDC estimates that nearly 1 in 68 children are diagnosed with Autism Spectrum Disorder (ASD). Children with autism require special services beyond the regular medical system– social services and supports. Last year, CMS, recognizing this special need, released guidance to states about how to provide services for these children under their Medicaid and CHIP programs. Check it out!

This week People are gathering from across the country to talk about Medicaid coverage of ASD in Iowa.

One major topic of that conversation will be how to improve medication management for children with ASD and other mental impairments. 2/3rds of children with ASD are prescribed antipsychotic medication, many more than one. One problem is that little is known about how long to keep kids on these medications or what effect they have on children when combined.

Medicaid covers about 1/3 of children with behavioral health disorders. It is increasingly important to the treatment and coverage of mental disorders and the directions that states take in this area can have broad impacts on the private market.

Colorado has been on the vanguard of accountable care in Medicaid. They started their Accountable Care Collaboratives in 2011 (the Affordable Care Act was just 1 year old!) with the goal of improving outcomes and saving money by using a medical home model embedded in a regional coordination strategy supported by strong data. Colorado Medicaid has produced this exciting YouTube video to teach us more!

As we look for evidence on how different models of ‘accountable care’ work, Colorado is great because they are a couple of years in and so are starting to produce some results. Plus, they’ve built strong data and analytics into their work to facilitate both patient care and evaluation. According to their 2014 Annual Report, last year the ACC overall (there are regional care organizations) generated $98-102 million in medical savings, and spent $69 million on administrative costs, for a net savings of $29-33 million.

Federal law requires state Medicaid programs to provide transportation to and from medical appointments (and related needs like picking up prescriptions). This is a really, really important benefit. Getting to the doctor can be difficult/impossible if your finances don’t allow you to own a car, or your health conditions prevent you from driving or taking public transportation (if it is available at all).

In practice, non-emergency medical transportation (NEMT) can be a big hassle. It could learn a thing or two from Uber when it comes to convenience. Drivers get lost or delayed, appointments get rescheduled last minute, and patients can end up waiting a long time. That said, it’s a great concept and NEMT programs could see quick improvements with better contracting and oversight between the state and companies who provide the services. NEMT is cheaper than using an ambulance, and ensuring that people can keep up with their appointments is far preferable to having people go to the emergency department for issues that could have been managed earlier.

Worrisomely, NEMT is one of the benefits that some states are looking to get exemptions from when they seek Medicaid expansion waivers. At a time when states like Oregon are showing that attention to social determinants of health matters for outcomes and cost, it seems counterproductive to weaken NEMT. Let’s hope that we can try improving non-emergency medical transportation services rather than losing this important benefit.

We May Already Know How To Reduce The High Cost Of Covering New Medicaid Enrollees

Unlike previous years, this annual report is making headlines because the actuaries project that for 2014 the newly eligible Medicaid expansion population will have costs greater than the non-newly eligible Medicaid population. Continue on to the next paragraph of the report and the actuaries write that a major contributor to this increased cost projection is that states anticipated and, in their managed care contracts, accounted for high first-year costs for these new beneficiaries.

We will see whether these projections come to bear in the next actuarial report or whether states in fact overestimated these first-year costs, perhaps leading actuaries to expect that the average per beneficiary cost for the expansion population will be less than the non-expansion population in later years.

While we still do not have final figures on how much new Medicaid enrollees spent on medical care in 2014, we do have evidence—including a recent study by Naderah Pourat and coauthors published in the July issue of Health Affairs—that primary care and care coordination can help reduce the initial care costs of Medicaid enrollees entering the health care system for the first time.

After all, evidencesuggests newly eligible Medicaid beneficiaries are healthier and less costly than the current Medicaid population. However, when negotiating their managed care contracts, many states estimated that the newly eligible would cost more in the first year than non-newly eligible individuals. This approach was based on the theory that the first newly eligible people to enroll would be those previously locked out of the insurance market, quickly entering the health care system with pent up demand. Additionally, they would be sicker and would require more health care services.

The estimations driven by this theory are essentially based on an adverse selection problem. But it doesn’t have to work that way. Pourat and colleagues show how, several years ago, California found a way to reduce the cost of newly insured Medicaid beneficiaries entering the health care system for the first time: care coordination.

Medicaid Expansion Presents An Opportunity

The stakes of getting this right have rarely been higher. Medicaid’s enrollment has grown by more than 12 million people since the Affordable Care Act’s first open enrollment period. The actuaries estimate that over four million people gained Medicaid coverage through Medicaid expansion in 2014, and many of these people are getting health coverage for the first time.

Studies, including the Oregon Health Insurance Experiment, show that expanding Medicaid coverage, absent care coordination efforts, increases the usage of often costly and ineffective emergency department visits. That phenomenon is not unique to Medicaid — insurance coverage reduces the financial barrier to seeking health care, driving up demand for services in all settings.

Unnecessary use of the emergency department is only a small portion of the costs associated with Medicaid. A vast majority of Medicaid enrollees go to the emergency department for actual emergencies. But, by promoting best practices of primary care adherence and encouraging beneficiaries to use of the right type of care, states like California can help reduce these initial cost increases associated with newly eligible enrollees.

The Medicaid expansion and enrollment increases represent an important opportunity for state and Medicaid managed care plans to actively reduce unneeded emergency department care. To do this, states have used methods ranging from out-of-pocket charges for emergency department trips deemed unnecessary to enrolling people in primary care practices with routine follow- ups.

Health Care Coverage Initiative

In 2005 California began implementing the Health Care Coverage Initiative that essentially acted as a medical home model for newly insured Medicaid beneficiaries in 10 counties around the state and gave enrollees a primary care provider that coordinated the person’s care.

In the initiative’s first two years, patients were not required to adhere to their chosen or designated primary care provider; they could switch providers whenever they wanted. As described in their recent Health Affairs article, Pourat and colleagues found that during this same period, the number of emergency department visits among beneficiaries remained high, attributed primarily to those enrollees who did not adhere to the same primary care provider. But that all changed in the third year when the county began actively requiring patients and providers to redirect care through their primary care provider. They instituted non-payment for visits to non-assigned providers and restricted primary care provider changes.

These policies led to greater adherence to primary care providers and reduced emergency department use and hospitalizations among enrollees who stuck with their primary care physician. While we already knew that greater continuity of care reduces emergency department usage and hospitalizations, this research provides additional evidence on the power of that payment methodology and policy structures to provide that continuity of care for Medicaid enrollees.

Next Steps

Orange County’s dual pronged financial and consumer approach to ensuring Medicaid enrollees seek care through a primary care provider is not the only way to increase primary care adherence and reduce use of the emergency department.

We need to closely study efforts to provide primary care services on nights and weekends and through retail clinics. Many newly eligible individuals have jobs without sick time that restrict their ability to make doctor’s appointments during the work week. But with these new efforts, Medicaid enrollees can get care on evenings or weekends, when many doctors’ offices are closed.

We also need to recognize which efforts have not delivered results. Evidence suggests that copayments and other restrictions on “unnecessary” emergency department visits does not reduce this utilization.

The research is unclear whether the temporary increase in Medicaid primary care payments from January 1, 2013 to December 31, 2014 led to increased utilization of primary care services by Medicaid enrollees. Starting in 2015 some states maintained the payment increases using their own funds, while others allowed the payments to return to earlier levels. This variation will allow researchers to further study the effect of provider payment on care utilization.

We have much to learn from the different approaches states are taking to reduce costs for people entering the health care system for the first time. And these lessons will have lasting relevance. In the years ahead we will continue to see long-term uninsured people entering the system. Care coordination will ensure that continuously insured people receive the right care, while saving money for states and the Medicaid program.